Correspondence
827
Intubation of the oesophagus There are many suggestions for reducing the incidence and severity of inhalation of stomach contents which is an ever present hazard and a particular problem during emergency anaesthesia. For several years I have used a method involving intubation of the oesophagus with a cuffed endotracheal tube. Such a tube is readily available and, when well lubricated, can be passed easily into the oesophagus. I have found this technique useful in two circumstances. Firstly when mechanical difficulties, for example associated with ankylosing spondylitis and rheumatoid arthritis of the neck, jaw or larynx, prevent endotracheal intubation even though this is indicated by the co-existence of intestinal obstruction or perforation haematemesis and emergency obstetric procedures requiring general anaesthesia. Secondly when speedy endotracheal intubation is impossible and copious regurgitation of intestinal contents occurs following an intravenous induction and the administration of a relaxant. In these circumstances the rapid passage of a cuffed endotracheal tube into the oesophagus will control the situation since, when the pharynx has been cleared, the patient can be ventilated using an airway and face-mask and the stomach emptied by a suction catheter passed through the endo-oesophageal tube. Having separated the gastro-intestinal and respiratory tracts determined efforts at endotracheal intubation can be made. These could include techniques such as blind or guided nasal intubation, the use of flexible fibre-optic endoscopy or the adoption of Water’s technique, in which an endotracheal tube is passed downwards around a fine catheter threaded up through the cricothyroid membrane into the pharynx. It is certainly worthwhile attempting these more complicated techniques when a long and difficult anaesthetic is anticipated and there are no other means of securing the airway. If endotracheal intubation proves impossible, the method of anaesthesia will depend upon personal choice; under emergency conditions my own practice is to spigot the endo-oesophageal tube, anchor it firmly and use an oral or naso-pharnygeal airway under a face-mask. Gloucestershire Royal Hospital, Gloucester
L. V. MARTIN
Another intubation hazard Foreign bodies, such as ampoule tops, needles, blood clot and inspissated vomit, may cause obstruction of endotracheal tubes and I now wish to draw attention to another cause of such hidden obstruction. This arises from the practice by some anaesthetists of using oral endotracheal tubes to assist in the passage of nasogastric tubes. Recently, during the cleaning of a 7.5 mm Magill tube, the proximal end of a Levin’s nasogastric tube was found obstructing the lumen. This hazard may be avoided if all endotracheal tubes are carefully inspected both by the staff who prepare them for use and by the anaesthetists who insert them. The photograph (Fig. 1 ) shows an endotracheal tube through which a Levin’s tube has been passed and, to the right of this, the concealed, detached rubber end of the nasogastric tube causing an obstruction.
Box Hill and District Hospital, Nelson Road, Box Hill, Victoria 3128, Australia
BEVERLEY PEERS
827
Intubation of the oesophagus There are many suggestions for reducing the incidence and severity of inhalation of stomach contents which is an ever present hazard and a particular problem during emergency anaesthesia. For several years I have used a method involving intubation of the oesophagus with a cuffed endotracheal tube. Such a tube is readily available and, when well lubricated, can be passed easily into the oesophagus. I have found this technique useful in two circumstances. Firstly when mechanical difficulties, for example associated with ankylosing spondylitis and rheumatoid arthritis of the neck, jaw or larynx, prevent endotracheal intubation even though this is indicated by the co-existence of intestinal obstruction or perforation haematemesis and emergency obstetric procedures requiring general anaesthesia. Secondly when speedy endotracheal intubation is impossible and copious regurgitation of intestinal contents occurs following an intravenous induction and the administration of a relaxant. In these circumstances the rapid passage of a cuffed endotracheal tube into the oesophagus will control the situation since, when the pharynx has been cleared, the patient can be ventilated using an airway and face-mask and the stomach emptied by a suction catheter passed through the endo-oesophageal tube. Having separated the gastro-intestinal and respiratory tracts determined efforts at endotracheal intubation can be made. These could include techniques such as blind or guided nasal intubation, the use of flexible fibre-optic endoscopy or the adoption of Water’s technique, in which an endotracheal tube is passed downwards around a fine catheter threaded up through the cricothyroid membrane into the pharynx. It is certainly worthwhile attempting these more complicated techniques when a long and difficult anaesthetic is anticipated and there are no other means of securing the airway. If endotracheal intubation proves impossible, the method of anaesthesia will depend upon personal choice; under emergency conditions my own practice is to spigot the endo-oesophageal tube, anchor it firmly and use an oral or naso-pharnygeal airway under a face-mask. Gloucestershire Royal Hospital, Gloucester
L. V. MARTIN
Another intubation hazard Foreign bodies, such as ampoule tops, needles, blood clot and inspissated vomit, may cause obstruction of endotracheal tubes and I now wish to draw attention to another cause of such hidden obstruction. This arises from the practice by some anaesthetists of using oral endotracheal tubes to assist in the passage of nasogastric tubes. Recently, during the cleaning of a 7.5 mm Magill tube, the proximal end of a Levin’s nasogastric tube was found obstructing the lumen. This hazard may be avoided if all endotracheal tubes are carefully inspected both by the staff who prepare them for use and by the anaesthetists who insert them. The photograph (Fig. 1 ) shows an endotracheal tube through which a Levin’s tube has been passed and, to the right of this, the concealed, detached rubber end of the nasogastric tube causing an obstruction.
Box Hill and District Hospital, Nelson Road, Box Hill, Victoria 3128, Australia
BEVERLEY PEERS
